BACKFLOW CERTIFICATION OF RE-CLAIMED WATER SYSTEMS CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS T ,� 3' BACKFLOW PREVENTION VALVE EXPERT
�►� 1�i INSTALLATION-REPAIRS-TESTING-CERTIFICATION
*BACKFLOW PREVENTION SPECIALISTS, INC,
LICENSED CONTRACTOR C.C.L.#427328CAI - _ )464-FLOW(3569)
3750-E CHARTER PARK DR.,SAN JOSE CA 95136-1356 T (408)269-2600
3608 FERNWOOD ST.,SAN MATEO CA 94403 Cu ��;GF
ertino FAX(408)269-2650
SERVICE ADDRESS 22350 Homestead Rd./x-Sweet Oak S[ MAK
MAILING ADDRESS Febco/SPX Valves CONTACT Tim
P.O. Box 8070 TEL# 800-972-0911
Fresno,CA 93747
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Febco 876 DC 4,. 0601231153
INTERNALIpd❑ff TAG LOCATION OF DEVICE
EXTERNALAp-
IF DEVICE IS A NEW INSTALLATION PLEASE CHECK THIS BOX[], PASEblt FAIL❑
• REDUCED PRESSURE DEVICES
PRESSURE TYPE
Shutoff Valves
DOUBLE CHECK VALVES VACUUM BREAKERS
DIFFERENTIAL
CHECK VALVE CHECK VALVE PRESSURE/RELIEF
AIR INLET CHECK VALVE
N0.1 N0.2 VALVE
#1 #2
CLOSED TIGHT CLOSED TIGHT OPENED AT_LES. OPENED AT—LES CLOSED TIGHT❑ CLOSED TIGK
�INITIAL p lbs. _ p lbs. /n OPENED UNDER 1.0 O LBS. LEAKED El ❑
TEST OPENED UNDER 2.0 R DID NOT OPEN❑
LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ LEAKED ❑
REPAIRS
AND
MATERIALS
USED
FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ LB CLOSED7TIGHTED]OPENED AT LBS PENED AT SED TIGHT❑ ❑
TEST LES ALBS pLBS
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
INITIAL TEST CERTIFIED TESTER NO. 10866 DATE 03-20-06
MO. DAY YR.
• REPAIRED BY
GATE
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.